The healthcare team is managing a client diagnosed with active pulmonary tuberculosis who also exhibits acute delirium and a high risk for falls. Which actions should the registered nurse include in the comprehensive safety plan? Select all that apply.
- Maintain the client in a negative-pressure airflow room with the door securely closed.Answer
- BAssign unlicensed assistive personnel to evaluate the client's cognitive status every two hours.
- Keep the client's bed in the lowest possible position with the wheels locked.Answer
- DApply bilateral soft wrist restraints to prevent the confused client from leaving the isolation room.
- Place a standard surgical mask on the client if transport outside the room is necessary for essential testing.Answer
- FInstruct all entering staff members to wear a standard surgical mask and a contact isolation gown.
Answer
The correct interventions are maintaining the client in a negative-pressure room with the door closed, keeping the bed in the lowest locked position, and placing a surgical mask on the client during transport.
Appropriate safety management for this complex client requires a combination of strict airborne precautions (negative-pressure room, client wearing a surgical mask when outside the room) and standard fall prevention measures (bed in the lowest position). These evidence-based interventions protect both the client from physical injury and the facility from infectious spread.
Step-by-Step Solution
Key Concept
Integration of Transmission-Based Precautions with Environmental Safety and Appropriate Delegation